Method for esophageal retraction

ABSTRACT

An instrument and method for retracting or repositioning a distal anatomic structure (organ) having a lumen (cavity) by remote manipulation. The method includes advancing the distal end of a flexible variform intraluminal member in a linear shape through a lumen (i.e., the esophagus) in the body to a distal location (the stomach), and deforming the distal end of the instrument to a rigid articulated (arched or curved) shape which retracts tissue surrounding the lumen. Further axial or rotational manipulation of a handle attached to the member correspondingly further retracts the distal anatomic structure to facilitate an endoscopic surgery.

RELATED APPLICATION

This application is a divisional application of Ser. No. 8/607,415 filedFeb. 28, 1996, now U.S. Pat. No. 5,787,897, issued Aug. 4, 1998, whichis a divisional application of Ser. No. 08/265,577 filed Jun. 24, 1994,now U.S. Pat. No. 5,558,665 issued Sep. 24, 1996.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates to surgical instrumentation and more particularlyto an instrument and method for retracting or repositioning a distalanatomic structure having a lumen to facilitate an endoscopic surgery.

2. Description of the Prior Art

In a "minimally invasive" endoscopic surgery, for example in aninsufflated abdominal cavity, dissection, cutting and suturing areperformed with various elongate instruments introduced into the interiorof the body through cannulas. It has been found that some endoscopicprocedures are complex and time-consuming because of difficulties inretracting or repositioning organs or structures with an elongateinstrument (e.g., a grasper). Since all such instruments are introducedthrough cannulas (tubes) which are in stationary positions, it often isdifficult to lift, rotate, reposition or otherwise retract an anatomicstructure to access the site of the actual procedure. On occasion, theretracting instruments have to cross the region of dissection,obstructing the surgeon's view and interfering with the dissectinginstruments.

An illustrative example of a procedure that is difficult to performendoscopically is a gastric wrap (e.g., a "Nissen fundoplication") foralleviating gastroesophageal reflux. In such a fundoplication, thesurgeon develops a fold or plication in the fundus of the stomach andthen wraps and sutures the plication generally around thegastroesophageal junction. To accomplish the procedure endoscopically,the surgeon must mobilize the esophagus and fundus by dissectingconnective tissues behind the structures, then grasp the exterior of thefundus and drag it behind and around the esophagus, then suture theplication in place. Such retraction procedures are difficult toaccomplish with conventional endoscopic graspers. An open surgery toaccomplish a fundoplication is undesirable because it requires lengthypostoperative recuperation and also requires a long disfiguring upperabdominal incision. There is therefore a need for new instruments andmethods for retracting or repositioning anatomic structures in a"minimally invasive" surgery and particularly for accomplishing theretraction of the esophagus and fundus in an endoscopic anti-refluxprocedure.

SUMMARY OF THE INVENTION

In general, the instrument of the present invention includes an elongatevariform intraluminal member having a substantially flexible primarylinear shape that is capable of being deformed into a substantiallyrigid non-linear secondary shape. The variform member is introduced inits linear shape into a lumen (cavity) in an anatomic structure in thebody in a proximal location in the primary shape, then advanced to adistal location within the lumen and thereafter deformed or articulatedinto the rigid secondary shape. The deformation of the variform memberinto the predetermined secondary shape retracts or repositions tissuesurrounding the lumen. Further manipulation of a proximal handle of theinstrument further repositions tissue.

In an exemplary method, assume that the surgeon wishes to retract orreposition the fundus of the stomach in an endoscopic Nissenfundoplication. Two variform intraluminal retractors are utilized. Bothretractors are flexible in a primary shape for introduction into thepatient's esophagus and stomach. Both retractors have a distal regionthat is deformable into a rigid secondary shape by actuation ofdeforming means at a proximal handle location. The esophageal retractorhas a "C"-shape and is utilized to arch the esophagus and thus mobilizethe distal esophageal region. The fundus retractor has a distal loop inthe secondary shape that resembles the loop in a "pig's tail." Thedistal loop along with a radially-projecting tip are adapted to reacharound and above the gastroesophageal junction and to exert forces onthe fundus to cause its transposition as the instrument is rotated aboutits axis. Such rotation of the retractor plicates the fundus wall andthereafter rotates the plication up to 360° around the esophagus so itcan be approximated with sutures or other adjoining means to theanterior aspect of the fundus which remains in its unretractedanatomical position.

In general, the present invention provides an instrument and methodutilized in an endoscopic surgery for retracting a distal anatomicstructure having a lumen, i.e., a hollow viscus (organ). The presentinvention also provides an instrument having a variform intraluminalmember capable of a flexible shape for introduction through a lumen in aviscus and a rigid articulated shape for repositioning the viscusintraluminally. The present invention also provides an instrument andmethod in which such intraluminal retraction is accomplished bymanipulation of the instrument from a proximal location.

The present invention also provides an instrument and method for ananti-reflux or gastric wrap procedure in which an intraluminal retractorplicates the region of tissue in the fundus of a human stomach which hasthe least resistance to such retraction (i.e., most mobile tissue) toprovide the most physiologically desirable wrap. The present inventionalso provides an instrument and method which allows for transpositioningthe wall of the fundus around the esophagus in a manner which makes itunnecessary to divide short gastric vessels. The present invention alsoprovides an instrument and method for retracting a human esophagus in amanner making it unnecessary to grasp the exterior of the esophagus witha grasping instrument.

The present invention also provides an instrument and method of theabove character in which the variform intraluminal member carries afiberoptic light means to transilluminate tissue for locating the regionof the instrument that is marked by the light. The present inventionalso provides an instrument and method in which the distal end of theintraluminal member has a pliable tip for leading the instrument througha lumen. The present invention also provides an instrument and method inwhich the intraluminal member incorporates a working channel toaccommodate an endoscope, an accessory instrument or for therapeuticagent delivery or suction. Additional advantages and features of theinvention appear in the following description in which severalembodiments are set forth.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an elevational view of a first embodiment of the presentinvention in a certain position.

FIG. 2 is an elevational view of a second embodiment of the presentinvention in a certain position.

FIG. 3 is an elevational view of a portion of the device of FIG. 1.

FIG. 4 is an elevational view of a portion of the device of FIG. 1 takenalong line 4--4 of FIG. 1 rotated 90°.

FIG. 5 is an elevational view of the portion of the device of FIG. 1taken along line 5--5 of FIG. 4 rotated 90°.

FIG. 6 is an elevational view of disposable sheath used in conjunctionwith the device of FIGS. 3-5.

FIG. 7 is a sectional view of the sheath of FIG. 6 taken along line 7-7of FIG. 1 rotated 90°.

FIG. 8 is a partial sectional view of a portion of the device of FIG. 1in a first position taken along line 8--8 of FIG. 1 rotated 90°.

FIG. 9 is an elevational view of the portion of the device in FIG. 8 ina second position.

FIG. 10 is an elevational view of a portion of the device of FIG. 2.

FIG. 11 is an elevational view of the portion of the device of FIG. 2taken along line 11--11 of FIG. 2 rotated 90°.

FIG. 12 is an elevational view of the device taken along line 12--12 ofFIG. 11.

FIG. 13 is transverse sectional view of the device taken along line13--13 of FIG. 11.

FIG. 14 is an elevational view of disposable sheath used in conjunctionwith the device of FIGS. 10-13.

FIGS. 15A-15E are schematic illustrations showing the manner in whichthe method of the present invention is practiced utilizing theinstruments of FIGS. 1 and 2.

FIG. 16 is a partial sectional view of a portion of an alternativevariform intraluminal member.

FIG. 17 is a partial sectional view of a portion of an alternativevariform intraluminal member.

FIG. 18 is a transverse sectional view of the variform member of FIG. 17taken along line 18--18 of FIG. 17 rotated 90°.

FIG. 19A-19B are alternative transverse sectional views of the variformmember of FIG. 17 taken along lines 19A--19A and 19B--19B of FIG. 17rotated 90°.

DESCRIPTION OF PREFERRED EMBODIMENTS OF THE INVENTION

By way of example, FIGS. 1 and 2 depict the variform intraluminalretractors to be employed in an endoscopic Nissen fundoplication.Esophageal retractor 5 illustrated in FIG. 1 is adapted for retractingor repositioning the esophagus and is shown in an articulated orsecondary shape. Fundus retractor 10 illustrated in FIG. 2 is adaptedfor repositioning the fundus of the stomach and is shown in anarticulated or secondary shape.

More in particular, esophageal retractor 5 has variform intraluminalmember 12 with proximal (near) and distal (far) regions respectively 13and 14 and medial (middle) region 15. Referring to FIGS. 3-5,intraluminal member 12 has a generally cylindrical shape alonglongitudinal axis 16 with an overall length of approximately 500millimeters. The cross-sectional dimension of intraluminal member 12when assembled with disposable sheath 18 (see FIGS. 6-7), furtherdescribed below, would range in diameters from #20 to #60 French forvarious patients.

Articulating retractor 5 is deformable to a rigid articulated orsecondary shape (see FIGS. 1 and 4-5) from the primary (straight) shape(see FIG. 3). Referring to FIG. 3, variform intraluminal member 12includes an interior assembly of longitudinal articulating elements, forexample elements 21 and 22, that are made of any suitable material suchas metal or plastic. Longitudinal bores 26a and 26b extend through eacharticulating element in substantial alignment. FIG. 5 illustrates atransverse sectional view of an articulating element. A tensioningmember with longitudinal-extending portions 27a and 27b is made offlexible braided stainless steel cable or another suitable material andextends through bores 26a and 26b. The distal ends of members 27a and27b are fixed with crimp nuts 28a and 28b (not visible) in tip 30 ofdistalmost articulating element 32. Proximal ends 33a and 33b of thetensioning members are secured in handle assembly 35 as described below(see FIGS. 1 and 8-9). In FIG. 3, the tensioning member portions areshown in a relaxed or non-tensioned position thus configuringintraluminal member 12 in the non-articulated flexible or primary shape.In FIGS. 4-5, the tensioning member portions are shown in a tensionedposition configuring intraluminal member 12 in the rigid articulated orsecondary shape.

As illustrated in FIGS. 3 and 4, the proximal planar abutment face 41aof articulating element 21 is angled with respect to axis 16 and abutssimilarly angled distal planar abutment face 41b of articulating element22. When tensioning members 27a and 27b are in a tensioned position asin FIG. 4, abutment faces 41a and 41b are in contact and form asubstantially rigid interface between articulating elements 21 and 22.In medial region 15 of intraluminal member 12, the abutment faces 42aand 42b of adjacent articulating elements, for example 43 and 44, have aconvex form when viewed in side elevation. When the tensioning member isin a tensioned position as in FIG. 4, convex abutment faces 42a and 42bare in contact and form a semi-rigid hinge connection 46 between thearticulating elements 43 and 44. Adjacent semi-rigid hinge connection 45results from similar convex abutment faces 47a and 47b except rotated90° (or another radial angle) along with tensioning portions 27a and27b. Thus, medial region 15 in intraluminal member 12 is flexible yetrotational forces applied to handle assembly 35 and proximal region 13are carried to the distal region 14.

The shape of distal region 14 of intraluminal member 12 in thearticulated or secondary shape exhibits a "C"-shape 49 with distalmosttip 30 extending substantially straight along axis 16. The "C"-shape 49has apex 50 illustrated with a radius 51 of approximately 60 mm. in FIG.4 but such radius may range from 30 mm. to 200 mm. and is not limiting.

Outer jacket 55 with proximal and distal ends, 56 and 57, is made of anysuitable flexible material, for example a thin wall elastomeric tubingsuch Tygon® R-1000. Jacket 55 may alternatively be fabricated of thinwall plastic such as PTFE® of FEP® that is flexible by bucklingslightly. When the articulating elements are in a non-tensioned position(see FIG. 3), jacket 55 assists in straightening medial region 15 anddistal region 14 of intraluminal member 12 to help the axial forcesapplied to handle assembly 35 generally along longitudinal axis 16 toassist in pushing intraluminal member 12 though the patient's esophagus.Jacket 55 is fixed over member 12 by metal band 58 compressed over thejacket. Jacket 55 has indicator stripe 59 extending along the length ofintraluminal member 12 for reasons explained hereinbelow. Optic fiber 60is incorporated into central bore 61 in intraluminal member 12. A lightsource is connected to proximal end 62 of optic fiber 60 for reasonsexplained below. The distal end 63 of optic fiber 60 terminates atdistalmost articulating element 32.

Referring to FIGS. 8-9, handle assembly 35 is generally cylindrical inshape and is suitable for grasping by the human hand. Proximal handle 64has reduced diameter cylinder portion 65 that telescopes in primaryaxial bore 66 in distal handle 67 (see FIGS. 8 and 9). Proximal handle64 has longitudinal bore 68 that is aligned with bores 26a and 26b inthe articulating elements and tension member portions 27a and 27b extendtherethrough. The proximal ends, 33 and 33b of the tensioning memberhave crimp nuts 69a and 69b crimped over said ends and abut the proximalface 70 of threaded adjustment nut 71. Nut 71 is disposed in femalethreads 72 within bore 73 of adjustment grip 75. Grip 75 is maintainedin axial relation to proximal handle 64 by lock ring 76 disposed incooperating annular grooves 77a and 77b in handle 64 and grip 75. Distalhandle 67 has secondary bore 78 with proximalmost articulating element79 fixed therein with adhesives or other suitable means.

A pair of opposing squeeze grips 84a and 84b are adapted to reciprocateproximal handle 64 relative to distal handle 67 in order to tension thetensioning member. Proximal and distal tensioning lever armsrespectively 85 and 86 pivot around proximal pins 87 and distal pin 88as well as intermediate pin 89. Inwardly directed force on the opposingsqueeze grips 84a and 84b directed toward axis 16 telescopes cylinder 65of handle 64 proximally from within axial bore 66 in distal handle 67 topull the tensioning member portions proximally (see FIG. 9). Rotation ofadjustment grip 75 adjusts the overall length of the tensioning memberwith respect to handle assembly 35 and the plurality of articulatingelements.

FIGS. 6-7 depict disposable sheath 18 that is adapted to be slipped overintraluminal member 12. Sheath 18 is made of transparent flexiblematerial such latex and has open proximal end 91 and closed distal end92 with very flexible tapered tip 93. As noted above, the outer diameterof sheath 18 would be manufactured in several sizes ranging from #20 to#60 French for different size esophageal lumens. Gripping collar 94molded into sheath 18 is adapted for grasping with the fingers to pullthe sheath over intraluminal member 12. Flexible working channel 95 withinterior lumen 96 is incorporated into sheath 18. The diameter of lumen96 may be any be any suitable dimension, for example from 0.6 to 3millimeters or more, to accommodate a flexible shaft accessoryinstrument (e.g., an endoscope or forceps). Working channel 95 also maybe utilized to deliver therapeutic agents to the patient's stomach or tosuction air or liquid secretions from the stomach.

Referring now to FIGS. 1 and 10-13, the other intraluminal retractioninstrument necessary for a fundoplication is fundus retractor 10 shownwith intraluminal member 112 having proximal and distal regionsrespectively 113 and 114 and medial region 115. Retractor 10 includesthe handle assembly 35 of the first-described retractor 5. Fundusretractor 10 is deformable between a flexible linear or primary shapealong axis 116 (see FIG. 10) and a rigid articulated or secondary shape(see FIGS. 11-13).

Fundus retractor 10 principally differs from esophageal retractor 5 inits articulated or secondary shape and in its cross-sectionaldimensions. Intraluminal member 112 has proximal and distal regionsrespectively 113 and 114 and medial region 115. Intraluminal member 112has a generally tubular shape along longitudinal axis 116 with anoverall length of approximately 800 millimeters. The diameter of member112 is dimensioned to cooperate with disposable sheath 118 (see FIG.14).

Intraluminal member 112 is made of an interior assembly of articulatingelements, for example elements 121 and 122, that is similar topreviously-described retractor 5. The distal region 114 may be deformedinto a loop 125 in its secondary shape. Tensioning member 127 is made upof portions 127a and 127b that extend in a loop around tip 129. Oneproximal end 133a of portion 127a is fixed with crimp nut 128 in theproximalmost articulating element (see FIG. 10). The other proximal end133b of tension member portion 127b is tensioned by actuation of thesqueeze grips in handle assembly 35 as described above. It is onlynecessary to tension portion 127b to articulate the intraluminal memberinto the secondary shape. The variously angled abutment faces, forexample 134a and 134b, cause intraluminal member 112 to deform into loop125 in a compound curved shape.

The distal region of intraluminal member 112 may take on varied shapesto accomplish its function of retracting the fundus, with such shapesgenerally exhibiting a distal curve shape with a tip projecting outwardfrom the axis of the instrument proximal to (above) the distal curve. Inone preferred embodiment shown in FIG. 11, the shape of distal end 114of intraluminal member 112 in the secondary shape is complex andgenerally resembles the loop of a "pig's-tail" with loop 125 terminatingin tip 129. Viewed in side elevation (see FIG. 11), loop 125 may turnfrom 200° to 360° from axis 116 until intraluminal member 112 crossesitself. In such side elevational view, loop 125 has a distal curveportion 130 with radius 131 dimensioned from 10 to 25 millimeters and aproximally-extending portion 133 extending from 0 to 40 millimeters, butsuch dimensions are not limiting.

In an elevational view from above as in FIG. 12, it will be noted thatloop 125 is skewed from axis 116 by angle "A" that may range from 5° to40°. FIG. 12 further illustrates that angle "A" provides gap "B" rangingfrom 5 to 30 millimeters where intraluminal member 110 crosses itselffor reasons described hereinbelow, with such dimensions not limiting.When viewed in transverse sectional view as in FIG. 13, the terminationportion 138 of loop 125 may curve around axis 116 and the medial region115 of intraluminal member 112 from 0° to 180° with gap "B" in anotherview ranging from 5 to 30 millimeters. Tip 129 is adapted to projectradially around or somewhat outwardly with respect to axis 116.

Outer jacket 155 with proximal and distal ends respectively 156 and 157is made of any suitable flexible material as described in conjunctionwith retractor 5 above. Indicator stripe 159 in included on jacket 155for reasons described below (see FIG. 12).

FIG. 14 depicts an elevational view of elongate disposable sheath 118with a central passageway 189 that is dimensioned to slide overintraluminal member 112 and is made of suitably flexible material suchas latex. The distalmost tip 190 is tapered and made of very flexiblematerial. The outer diameter of the medial region 192 of sheath 118 isillustrated in diameter #50 French but would be manufactured indiameters ranging from #40 to #60 French for different patients withdifferent size esophaguses and for different gauge gastric wraps. Theproximal and distal regions respectively 193 and 194 of the sheath havethin walls.

Inflatable collar 195 capable of collapsed and inflated conditions isdepicted in FIG. 14 in an inflated condition. Collar 195 is incorporatedinto sheath 118 in medial region 192 with inflation tube 196 extendingto a proximal location along handle assembly 35. Collar 195 ispreferably made of elastomeric material, for example latex, and isinflatable to a diameter of approximately 40 to 50 millimeters. ALuer-type fitting 197 at the proximal end 198 of tube 196 is adapted forcooperating with an inflation source supplying an inflation medium, forexample air or saline solution from a syringe (not shown).

Operation and use of the instruments shown in FIGS. 1 and 2 inperforming the method of the present invention is described briefly asfollows. Assume that the surgeon is to perform an endoscopic Nissenfundoplication, although the device may be used in an open surgicalprocedure. The surgeon prepares the patient with a suitable anesthesia,insufflates the abdominal cavity and places three or more cannulaassemblies through the abdominal wall, for example using the safetyheliscopic cutter disclosed in co-pending patent application Ser. No.08/187,753 filed Jan. 26, 1994 now abandoned and the "inside-out" trocardisclosed in commonly invented patent application Ser. No. 08/255,273,docket No. M-2890, filed Jun. 1, 1994 entitled "Instrument and Methodfor Performing Surgery Around a Viewing Space in the Interior of theBody" now U.S. Pat. No. 5,569,183 issued on Oct. 29, 1996, bothincorporated by reference. The surgeon then utilizes an endoscope toview the interior of the body in the region of the gastroesophageal orGE-junction and stomach.

Both retractors 5 and 10 are prepared by placing disposable sheaths 18and 118 over the variform intraluminal members respectively 12 and 112of each retractor. The surgeon's assistant then grasps retractor 5 andconfigures variform member 12 in the primary shape by opening squeezegrips 84a and 84b outwardly from axis 16 (see FIG. 3) so that the medialregion 15 and distal region 14 of intraluminal member 12 aresubstantially straight and flexible. The assistant introduces tip 30with flexible tip 93 of sheath 18 through the patient's mouth intoesophagus 200 and advances intraluminal member 12 distally until tip 30is in the region of GE-junction 202 or slightly within stomach 204 (seeFIG. 15A). A light source connected to optic fiber 60 emits a lightthrough tip 30 of intraluminal member 12. The surgeon can see a spot oflight through the translucent tissue of the esophagus to locate the tipof the instrument. It should be appreciated that the light may beemitted from any appropriate point within the distal region 14 of theintraluminal member to function as a locator.

The assistant turns the instrument to a correct angle by reference toindicator stripe 59 which can be seen through transparent sheath 18 andis in angular registration with distalmost tip 30 such that apex 50 of"C"-shape 49 is disposed toward the front of the patient's body (seeFIG. 15B). While the surgeon views the distal esophagus 207endoscopically, the assistant applies pressure on squeeze grips, 84a and84b, directed toward axis 116 which pulls the distal ends 33a and 33b ofthe tensioning member proximally and deforms the articulating elementsof intraluminal member 12 into the articulated or secondary shape (seeFIG. 15B).

The diameter of retractor 5 fits somewhat loosely in esophageal lumen208 and the articulation of retractor 5 causes the exterior of esophagus200 to assume the "C"-shape 49 of the retractor. Such retraction causesesophagus 200 to arch outwardly above GE-junction 202 thus retractingand mobilizing the distal esophagus 207 by stretching and dissectingconnective tissues. The surgeon's assistant may rotate retractor 5 and"C"-shape 49 in an arc of approximately 90° to 180° to further dissectconnective tissues. Thereafter, the surgeon may easily dissect remainingconnective tissues intact behind the mobilized esophagus with anaccessory instrument (e.g., a grasper). Thereafter, the assistant openssqueeze grips, 84a and 84b, outwardly from axis 116 (see FIGS. 7-8) toreturn intraluminal member 12 to its primary shape and withdraws theretractor 5 from esophagus 200.

During the procedure, working channel 95 incorporated into disposablesheath 18 may be used to introduce a fiberscope or other accessoryinstruments into the stomach. Alternatively, the working channel may beused to suction air or secretions from the stomach or to delivertherapeutic agents.

The surgeon's assistant next grasps fundus retractor 10 in its straightand flexible or primary shape (see FIG. 10) and introduces intraluminalmember 112 into the patient's esophagus 200 and stomach (via his mouth)204 as shown in an alternative phantom view in FIG. 15C. The assistantthen inflates inflatable collar 195 with an inflation medium, forexample air or saline solution from a syringe (not shown). Collar 195 issufficiently large to prevent it from passing through GE-junction 202 asthe intraluminal member 112 is moved proximally. The assistant thenadjusts retractor 10 to the correct radial angular position by rotatingthe retractor 10 until indicator stripe 159 is facing the front of thepatient's body. The assistant then applies inward pressure on thesqueeze grips in handle 35 to articulate the distal end 114 ofintraluminal member 112 to the looped or secondary shape (see FIGS.10-13). In an alternative phantom view in FIG. 15C, retractor 10 isarticulated to the secondary shape at which time the surgeonendoscopically can view the wall of fundus 215 "tenting" outwardly astip 129 and terminal region 138 exert forces on the wall and beginrepositioning the fundus.

The particular secondary shape of distal region 114 of the instrument isadapted to accomplish several objectives (see FIGS. 11-13). Thedistalmost loop portion 130 is adapted to extend through esophagus 200and generally curve closely around GE-junction 202 with the saidjunction fitting into gap "B" (see FIGS. 12-13). The diameter of medialregion 192 of sheath 118 is selected to gauge the diameter of thegastric wrap. The medial region 192 fits snugly inside esophageal lumen208 and GE-junction 202 to intraluminally support the lumen as plication210 is rotated around the esophagus and approximated.

Intraluminal retraction or repositioning of the fundus 215 offers a veryimportant advantage over currently practiced methods which retract thefundus typically by grasping and pulling on its exterior wall. In suchcurrent practice, it is necessary to ligate and divide one or more shortgastric vessels 211 (see FIG. 15A) between the spleen and stomach inorder to mobilize the fundus for wrapping around the esophagus. Incontrast, in an intraluminal retraction with instrument 10, it shouldnot be necessary to divide any short gastric vessels to accomplish thefundoplication. The proximally-extending portion 133 of loop 125 isadapted to reach proximally well above GE-junction 202 and tip 129 andterminal portion 138 thus engage the softest tissue in the inner wall offundus 215. Proximal and rotation forces on the instrument may cause tip129 and terminal portion 138 to slip at first until loop 125 encountersthe most pliable tissue of the fundus which then plicates easily. Inthis manner of utilizing the instrument, only the least resistant (mostmobile) tissue plicates which is physiologically desirable. The moreresistant tissue of the fundus, including tissue which is overlain witha gastric artery 211, typically should resist plicating and such tissuewill remain unretracted thus making it unnecessary to divide a shortgastric vessel.

FIG. 15C depicts intraluminal member 112 in a somewhat distal positionafter being deformed to the secondary position. The surgeon instructsthe assistant to lift intraluminal member 112 to a more proximalposition until balloon 195 abuts the GE-junction. Thereafter, theassistant rotates handle assembly 35 and intraluminal member 112counterclockwise while the surgeon endoscopically views the wall offundus 215 tenting further and then developing plication 210. Theassistant continues counterclockwise rotation until plication 210 isretracted and wrapped around distal esophagus 207 as shown in FIG. 15D.In FIG. 15D, note that tip 190 of sheath 118 is sufficiently flexible tobend over and play no role in the plication of tissue. The compoundradiuses around loop 125 are adapted to overcome counterforces caused bythe fundus' resistance to rotation. Such counterforces are generallyopposed by directing all rotational forces applied to handle assembly 35along the continuously curved axis of intraluminal member 112.

When plication 210 is in the desired location as shown in FIG. 15D, thesurgeon places several sutures 222 through the plication, distalesophagus 207 and fundus 215. FIG. 15E depicts a completedfundoplication with the instrument in phantom view reconfigured to itsprimary shape for withdrawal from the esophagus.

It should be appreciated that fundus retractor 10 may be provided with afiber optic light source as in esophagus retractor 5, although not sodescribed herein.

FIG. 16 depicts a partial sectional view of an alternative embodiment ofa variform intraluminal member 312 with "sequential" deforming means foruse with any intraluminal retractor. The variform member 312 showsrepresentative articulating elements 321 and 322 in a deforming positionbetween the primary and secondary shapes (shown in phantom view).Tensioning members 327a and 327b are slidably disposed in longitudinallyextending bores 328a and 328b. Compression spring 330 is disposed aroundtensioning member 327b and within partial bores 335 and 337 in theadjacent articulating elements. Other compression springs, for examplespring 338, are likewise disposed between other articulating elementsand each spring may have a different spring rate, i.e., the amount offorce required to compress the spring. Elastomeric jacket 355 is shownin phantom view.

The operation of a retractor incorporating variform member 312 willfollow the procedures described above in connection with retractors 5and 10. The variform member 312 differs from the previously describedembodiments in that member 312 sequentially deforms between the primaryand secondary positions in a predetermined manner. Since each spring,for example 330 and 338, may have a different spring rate, as tensioningmember 327b is pulled proximally to deform variform member 312 to thesecondary shape from the primary shape, the weakest rate spring willcompress first and the strongest rate spring will compress last. Thus,it is possible to provide a "sequential" deforming structure withcertain elements of variform member 312 or certain regions of member 312deforming in sequence. Such sequential deforming may be useful fordeforming a variform intraluminal member in a restricted space. Forexample, referring to fundus retractor 10 in FIGS. 10-13, it may beuseful to provide intraluminal member 112 with a sequential deformationin which tip 129 and termination region 138 deform last to wrap thedistal end 114 of the member around axis 116 (see FIG. 10).

FIGS. 17-18, 19A and 19B depict a partial sectional view of analternative embodiment of a variform intraluminal member 412 whichdiffers from esophagus retractor 5 only in construction of thearticulating elements in intraluminal member 412. The cooperatingarticulating elements are made of plastic or other suitable material,for example elements 421 and 422, and are adapted for partiallytelescoping or nesting with one another to add rigidity to member 412 inthe rigid articulated or secondary shape shown in FIG. 17. The primaryshape is shown in phantom view in FIG. 17. Articulating element 421 withmale protruding form 425a is configured to mate with adjacentarticulating member 422 and its female receiving form 425b. The adjacentarticulating members may be deformed between the secondary shape and thelinear flexible primary shape by singular tensioning member 427 thatextends longitudinally through bore 428 and is tensioned in the mannerhereinbefore described with handle 35. FIG. 18 depicts a transversesectional view through protruding form 425a and receiving form 425b inthe secondary position. It will be noted that the mating male and femaleforms in sectional view are non-round or "keyed" to maintain the desiredradial angular registration between adjacent elements 421 and 422 inorder to maintain the secondary shape.

A unitary sequential deforming structure may be incorporated intovariform member 412 and is illustrated in FIGS. 19A-19B in connectionwith articulating elements 429 and 430. Articulating element 429 is madeof a resilient molded plastic, and has a substantially rigid maleprotruding form 435a (see FIG. 17). The female receiving form 435b ofelement 430 (see FIG. 17) has a somewhat thin wall section and is moldedof resilient plastic in an "out-of-round" or mis-shapened cross-sectionin its repose state with respect to cooperating male form 435a as shownin FIG. 19A. Thus, when tensioning member 427 is tensioned to press maleform 435a into female form 435b, the axial forces on male form 435a mustovercome the resilient spring-like forces within the mis-shapened femaleform 435a to re-shape said female form to accommodate the male form, asdepicted in FIG. 19B. By varying the types and densities of plastic inthe female form 435b in its repose state, the spring-like resilientforces integral to each articulating element can be varied. Thus, it canbe appreciated that such varied rates spring-like resilience in femaleforms in different articulating elements can be utilized as a means ofsequencing the deformation of member 412 between the primary andsecondary shapes. It should be appreciated that variform member 412alternatively could be provided with compression springs disposed aroundtension member 427 to provide sequential deforming means and be withinthe scope of the present invention.

From the foregoing it can be seen that there is provided an instrumentand method that will greatly facilitate surgical procedures,particularly endoscopic procedures, by allowing the retracting of theesophagus and fundus by intraluminal manipulation from a proximallocation. The above-described esophagus retractor additionally may beutilized to facilitate a thoracoscopic truncal vagotomy, an esophagealmyotomy, or a sympathectomy. The fundus retractor also may be utilizedin a Guarner partial fundoplication as well as other variations ofgastric wrap procedures. It can be readily seen that the instrument ofthe present invention can be manufactured with other specialized shapes,diameters and embodiments to intraluminally retract or reposition otheranatomic structures having a lumen, for example the trachea, thebronchial passages or the colon. Alternative embodiments in very smalldiameters may be used to intraluminally retract structures such as veinsand arteries. It should be appreciated that an intraluminal retractorfor such applications may range in diameter from 1 millimeter or less to40 millimeters or more and have any required length to accomplish aparticular retraction.

This disclosure is illustrative and not limiting; further variationswill be apparent to one skilled in the art in light of this disclosureand are intended to fall within the scope of the appended claims.

I claim:
 1. A method for repositioning a patient's esophagus, using anelongate variform member having a distal region that is deformablebetween a substantially flexible linear and an arched shape,comprising:introducing the distal region of the variform member throughthe patient's mount into the esophagus in the linear shape; anddeforming the distal region of the variform member to the arched shapefrom the linear shape, thereby positioning and arching the esophagusfrom within its interior.
 2. The method of claim 1, together withlocking the variform member in the arched shape.
 3. The method of claim1, together with manipulating the variform member in an axial directionto further retract the esophagus axially while the variform member is inthe arched shape.
 4. The method of claim 1 together with manipulatingthe variform member rotationally to further retract the esophagusrotationally while the variform member is in the arched shape.
 5. Themethod of claim 1, further comprising viewing the interior of thepatient's stomach through a lumen associated with said variform member.6. The method of claim 1, further comprising:placing at least one sleevethrough an abdominal wall of the patient; disposing an endoscope in thesleeve; and viewing through the endoscope a region of the patient'sgastroesophageal junction.
 7. The method of claim 1, furthercomprising:transmitting light from a projecting distal tip portion ofsaid variform member, thereby illuminating a portion of the esophagus;and observing endoscopically the illuminated portion of the wall of theesophagus from the exterior of the esophagus.
 8. The method of claim 1,wherein the arched shape has a radius in a range of 30 mm to 200 mm. 9.The method of claim 1, wherein the esophagus is arched by the deformingat the patient's gastroesophageal junction.
 10. A method ofrepositioning a patient's esophagus using an elongate member at leastpartially deformable between a substantially linear shape on a curvedshape, comprising:introducing at least a portion of the member throughthe patient's mouth into the esophagus in the linear shape; anddeforming at least a part of the member in the esophagus into the curvedshape, thereby arching the esophagus.